Chapter 3 - Use and Abuse of Psychoactive Prescription Drugs and Over-the-Counter Medications

Adults age 65 and older consume more prescribed and over-the-counter medications than
any other age group in the United States. Although older adults constituted less
than 13 percent of the population in 1991, they received 25 to 30 percent of all
prescriptions (Woods and Winger, 1995;
Ray et al., 1993; Sheahan et al., 1989) and experienced more
than half of all reported adverse drug reactions leading to hospitalization
(Chastain, 1992). Some 80 to 86 percent of
older adults over age 65 reportedly suffer from one or more chronic diseases or
conditions(Administration on Aging and Staff of the U. S.
Senate Special Committee on Aging, 1991;
U. S. Bureau of the Census, 1996), and an
estimated 83 percent of adults over 65 take at least one prescription drug (Hazelden Foundation, 1991; Ray et al., 1993). In fact, 30 percent of
those over 65 take eight or more prescription drugs daily (Sheahan et al., 1989).

A large share of prescriptions for older adults are for psychoactive, mood-changing
drugs that carry the potential for misuse, abuse, or dependency. In 1983, one-fourth
of community-dwelling older adults used psychotherapeutic drugs on a regular basis
for sleep disorders or chronic pain as well as for anxiety and labile mood (Finlayson, 1995b). Approximately 25 to 28
percent of older adults reported use of a psychoactive drug within the last year,
and 20 percent used a tranquilizer daily. Indeed, 27 percent of all tranquilizer
prescriptions and 38 percent of hypnotic prescriptions in 1991 were written for
older adults. Moreover, older adults are apparently more likely to continue use of
psychoactive drugs for longer periods than their younger counterparts
(Sheahan et al., 1995; Woods and Winger, 1995).

This chapter focuses on the most commonly prescribed abusable psychoactive
medications for older adults - benzodiazepines, antidepressants, and opiate/opioid
analgesics. Also covered are risk factors that make older adults more vulnerable to
misuse and abuse of these substances; adverse effects associated with consumption of
psychoactive medications; and uses for, effects of, and alternatives to different
categories of prescription drugs.

Evolution of Psychoactive
Prescribing

Since their introduction in the late 1950s, benzodiazepines have become the most
widely prescribed anxiolytics and hypnotics in medical practice. Their growing
use throughout the 1960s prompted many to ask whether the United States was
becoming an overmedicated society in which people would take a pill for any
physical or emotional pain rather than exert some simple self-control. Some
researchers feared that use of prescribed psychoactive drugs for a vast array of
conditions would inexorably lead to irresponsible recreational use or
physiological dependence on licit or illicit substances. Others thought that
prevalence of associated psychosocial problems would rise along with the
prescription drug use (Balter, 1973;
Manheimer et al., 1973; Cooperstock and Parnell, 1982).

Yet studies of older populations conducted over the past 20 years have generally
found that most adults who take psychoactive medications do not intend to abuse
them. The drugs usually are obtained with an appropriate prescription from a
primary care physician for a specific health-related purpose and are primarily
used in conjunction with a physical condition or to alleviate symptoms of
emotional stress (Piland, 1979; Guttmann, 1977; Cooperstock and Parnell, 1982). In fact, there has been
a steady improvement in prescribing practices and safe and appropriate
medication use in the last 25 years.

Misuse and abuse of prescriptions have dwindled over that time for several
reasons: (1) safer drugs with fewer undesirable side effects are constantly
being developed by pharmaceutical companies, especially for common health and
mental health problems; (2) ever-changing Federal and State regulations seek to
protect consumers from hazardous substances and to restrict undesirable provider
practices; (3) guidelines and protocols recommending best practices are being
developed and disseminated to health care providers; (4) more physicians are
receiving training relevant to the care of older patients (from geriatric
research, education, and clinical centers); and (5) consumers are being educated
by their physicians and other health care providers, pharmacists, and various
media sources regarding the dangers of drug interactions and the importance of
medication compliance for positive therapeutic outcomes.

More specifically, benzodiazepines with a lower addiction potential and fewer
adverse interactions with other medications have replaced many of the older
barbiturates, bromides, meprobamate, and neuroleptics for management of anxiety,
especially acute situational anxiety, generalized anxiety disorder, and
associated transient insomnia. Similarly, in the 1960s, the benzodiazepine
flurazepam (Dalmane) replaced many of the barbiturates and nonbarbiturates
routinely used for sleep disorders and insomnia complaints. Displaced drugs
included such barbiturates as pentobarbital (Nembutal), secobarbital (Seconal),
and the combination aprobarbital and secobarbital (Tuinal), as well as the
nonbarbiturates chloral hydrate, ethchlorvynol (Placidyl), and glutethimide
(Doriden) (Fouts and Rachow, 1994;
Finlayson, 1995b;
Rickels and Schweizer, 1993). Sales
reports and pharmacy prescription audits reflect the overall decline in the
numbers of stimulant and barbiturate prescriptions, with minor tranquilizers
and/or sedatives exceeding other classes since the 1980s (Cooperstock and Parnell, 1982). Prescriptions for the
popular anxiolytic benzodiazepines have more recently shifted from diazepam
(Valium) to the shorter acting compounds, particularly alprazolam (Xanax) and
lorazepam (Ativan), and from the earlier long-acting benzodiazepine hypnotic,
flurazepam, to the shorter acting triazolam (Halcion) and temazepam (Restoril).
Overall, sales of benzodiazepine anxiolytics have decreased, whereas use of
benzodiazepines as sleep-inducing hypnotics has increased or remained stable
(Winger, 1993; Woods and Winger, 1995).

In 1996, the top 10 drugs prescribed in nursing homes included two selective
serotonin reuptake inhibitors (SSRIs), sertraline (Zoloft) and fluoxetine
(Prozac), as well as the nonbenzodiazepine anxiolytic, buspirone (BuSpar). This
represents a decrease from 1970, when 8 of the top 10 nursing home prescriptions
were for psychoactive drugs (Prentice,
1979). Furthermore, chronic pain from such conditions as
arthritis is more frequently treated now with nonsteroidal anti-inflammatory
agents rather than with opiate-containing drugs such as acetaminophen with
codeine (Finlayson, 1995b). Yet even
though fewer prescriptions for psychoactive drugs are being written for older
adults, many patients prescribed these drugs still misuse and abuse them, and
some health care providers continue to exhibit poor judgment in their
prescribing and monitoring practices.

Patterns of Use

The drug-taking patterns of psychoactive prescription drug users can be described
as a continuum that ranges from appropriate use for medical or psychiatric
indications through misuse by the patient or the prescribing health care
practitioner to persistent abuse and dependence as defined by the American
Psychiatric Association's criteria in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition
(DSM-IV) (American Psychiatric
Association, 1994) (see Figure
3-1). Because older adults are less likely to use psychoactive
medications nontherapeutically, problems with drugs generally fall into the
misuse category and are unintentional. For example, older patients are more
likely to misunderstand directions for appropriate use - a problem that is
compounded by the multiple prescriptions they receive, often from multiple
physicians unaware of a colleague's treatments. In these circumstances,
overdose, additive effects, and adverse reactions from combining drugs are more
likely to occur. Unintentional misuse can, however, progress into abuse if an
older adult continues to use a medication nontherapeutically for the desirable
effects it provides, much as an abuser of any drug does.

Adults can become physiologically dependent on psychoactive medications without
meeting dependence criteria. Tolerance and physical dependence can develop when
some psychoactive medications (e.g., benzodiazepines, opioids) are taken
regularly at the therapeutically appropriate dose for relatively brief periods.
An abstinence syndrome or withdrawal effects may occur if the drug is stopped
precipitously. This type of iatrogenically induced physiological dependence is
not usually accompanied by any tendency on the part of the patient to escalate
dosage during or after medically supervised withdrawal, to experience cravings
after discontinuation, or to subsequently continue use or addictive behavior
(Woods and Winger, 1995; Portenoy, 1993). In other words, adults
can become dependent on psychoactive medications without realizing it.

Risk Factors for Misuse And Abuse of Psychoactive
Drugs

A variety of factors influence the use and potential for misuse or abuse of
psychoactive prescription drugs and over-the-counter medications by older
adults. The aging process, with its physiological changes, accumulating physical
health problems, and other psychosocial stressors, makes prescription drug use
both more likely and more risky. The most consistently documented correlates of
psychoactive prescription drug use are old age, poor physical health, and female
gender (Cooperstock and Parnell, 1982;
Sheahan et al., 1989; Finlayson, 1995b).

Among older women, use of psychoactive drugs is correlated with middle- and
late-life divorce, widowhood, less education, poorer health and chronic somatic
problems, higher stress, lower income, and more depression and anxiety (Gomberg, 1995; Closser and Blow, 1993). Major losses of economic and
social supports, factors related to the provider and health care system, and
previous or coexisting drug, alcohol, or mental health problems also seem to
increase vulnerability for misusing or abusing prescribed medications.

Data from the 1984 Epidemiological Catchment Area (ECA) survey
(Regier et al., 1988) confirm that
anxiety disorders are relatively prevalent in the general population of adults
older than 65, with 7.3 percent of older respondents reporting an incidence
within the past month. Older women are nearly twice as likely as older men to
develop a diagnosable anxiety disorder. Bereavement precipitates anxiety in
nearly one-fourth of survivors during the first 6 months following the death of
a loved one and in nearly two-fifths of those left behind during the second
6-month period. Anxiety is also common after a severe traumatic event (Salzman, 1993a).

System and Environmental
Influences

A variety of health care system-related and environmental factors also place
older adult users of psychoactive prescription drugs at risk for misuse of
these substances, serious adverse effects, or abuse and dependence.
Potentially dangerous prescribing practices include ordering medications
without adequate diagnoses or other documented indicators of symptoms,
prescribing them for too long a time without appropriate medical monitoring
of drug reactions and patient compliance with the prescribed regimen,
selecting drugs known to have a high potential for side effects in older
adults at the doses given, ordering drugs without knowing or reviewing
whether they interact adversely with other medications the patient is
taking, and failing to provide adequate and comprehensible instructions for
patients regarding how and when to take medications and what side effects to
expect and report. Drug misuse also includes failure to consider the
influence of aging on the effects of drugs in the body (see Figure 3-2).

Previous History of Substance Abuse or Psychiatric
Disorder

Although most experts agree that nonmedical use or abuse of benzodiazepines
is rare at any age and household surveys indicate that nonmedical use is
declining (Salzman, 1993b; Barnas et al., 1992), some liability
for abuse of the benzodiazepines does seem to exist in the following
cohorts: (1) light-to-moderate alcohol drinkers who have been demonstrated
to prefer diazepam over placebo and may be vulnerable to the reinforcing
properties of these drugs; (2) adults with histories of sedative abuse,
abuse of multiple drugs, and methadone-maintained clients; and (3) patients
who have developed physiological dependence on benzodiazepines after
long-term use and are experiencing acute withdrawal effects following abrupt
discontinuation (Salzman, 1993b;
Barnas et al., 1992).

However, continued craving for the medication does not seem to persist among
adults who fit none of the categories above and who have successfully been
withdrawn from benzodiazepines. By contrast, adults with histories of
substance abuse prefer benzodiazepines to placebo. They also prefer,
however, older anxiolytics and hypnotics such as methaqualone (Quaalude) or
meprobamate (Miltown) to benzodiazepines (Winger, 1993; Woods and
Winger, 1995). The benzodiazepines preferred by sedative abusers
and methadone maintenance clients seem to be diazepam, lorazepam, and
alprazolam (Woods and Winger,
1995). Unfortunately, little is known about the risk potential for
these individuals in late life.

Data from the Mayo Clinic further suggest that psychiatric diagnoses may be a
risk factor among older adults for abuse of and dependence on prescription
drugs (Finlayson, 1995a). In this
study, rates of mental disorder diagnosis in 100 older adults hospitalized
for prescription drug dependence included the following disorders: mood (32
percent), organic mental (28 percent), personality (27 percent), somatoform
(16 percent), and anxiety (12 percent). The patient group was predominantly
female, and some patients had more than one mental disorder diagnosis. The
patient group was identified as having considerable psychopathology by
several other measures as well (Finlayson,
1995a). Although research on older drug addicts is rare, at
least one study indicates that older patients with substance dependence
disorders are more likely than younger drug addicts to have a dual
diagnosis. In this investigation, only 15 percent of older drug-dependent
patients had a substance abuse diagnosis without a coexisting psychiatric
disorder compared with 64 percent of younger counterparts. These researchers
concluded that older adults with a preexisting psychiatric disorder may be
more at risk for concurrent prescription drug dependence (Solomon et al., 1993).

Adverse Effects

The chronic administration of psychoactive substances to older adults, even at
therapeutic doses, has been associated with a variety of adverse central nervous
system effects, including diminished psychomotor performance, impaired reaction
time, loss of coordination, ataxia, falls, excessive daytime drowsiness,
confusion, aggravation of emotional state, rage, and amnesia as well as the
development of physiological dependence manifested by withdrawal effects when
the drugs are suddenly discontinued (Fouts
and Rachow, 1994). Psychoactive medications have been implicated in
23 percent of adverse drug reactions among nursing home residents (Joseph, 1995). Side effects from these
drugs range from constipation, dry mouth, or urinary difficulty to such severe
reactions as hip fractures from falls, withdrawal seizures or delirium, and
worsened depression leading to suicide attempts (American Psychiatric Association, 1994). However, all
undesirable reactions may be more serious in frail older adults and in those
with multiple chronic diseases and cannot be ignored
(Lapane et al., 1995; Solomon et al., 1993).

Anxiolytics

Figure 3-3 summarizes information
about some of the anxiolytics most frequently prescribed for acute or
chronic anxiety in older adults. The figure depicts the generic and most
usual brand name for these medications as well as the elimination half-life
or duration of action in the body. Note that Figures 3-3 and 3-4 both contain the names of benzodiazepines_their designations
as anxiolytics or sedative/hypnotics are
based on properties that drive marketing decisions. Some physicians may
choose, for example, to use lorazepam as either an anxiolytic or sedative
depending on the circumstances.

An estimated 95 percent of benzodiazepine prescriptions for older adults in
this country are ordered for anxiety and insomnia, with only 5 percent used
as adjuncts for general anesthesia, as muscle relaxants, or as
anticonvulsants (Ray et al.,
1993). Numerous studies, including the 1990 American Psychiatric
Association Task Force report, have concluded that the vast majority of use
of these agents is appropriate, with only occasional overprescribing by
physicians for some patient subgroups or misuse by patients (Salzman, 1990, 1993b; Winger,
1993; Woods and Winger,
1995). Even among the small group of respondents to household surveys
who have acknowledged taking benzodiazepines that were not prescribed for
them (less than 6 percent), the vast majority borrowed pills from
significant others and used them for symptom relief, not recreational
purposes. Moreover, worldwide experience with the short-term use of
benzodiazepines to relieve acute anxiety, situational stress, and transient
insomnia indicates that these medications are unusually safe and
efficacious, with very little liability for dose increases, prolonged use,
or addictive dependence (Salzman,
1993b).

Although most people use benzodiazepines for short periods of time without
developing problems, others take them past the point where they are
effective and thus are at risk for adverse effects including tolerance and
abuse. By 1990, as many as a fourth of anxiolytic users had taken these
medications for a year or more (Winger,
1993). Several studies in the United States and Britain confirm
that long-term users (for a year or more) of benzodiazepines are likely to
be older than age 45 and female with substantial psychological stress,
dysphoric or depressive symptoms, and multiple chronic physical illnesses or
somatic problems (Salzman, 1993b;
Winger, 1993). Benzodiazepine
use for longer than 4 months is of particular concern among older adults.
The physiological aging process decreases the body's ability to absorb and
metabolize drugs, allowing the drug to accumulate more rapidly than in
younger people and increase the likelihood of toxicity and adverse effects.
Benzodiazepines have variable rates of absorption, with metabolism occurring
primarily in the liver. Because the longer acting benzodiazepines have
active metabolites, some of which have very long half-lives - up to 200
hours in the case of flurazepam - the duration of action is often longer
than expected. They are also more likely to produce residual sedation and
other adverse effects such as decreased attention, memory, cognitive
function, and motor coordination and increased injurious falls or motor
vehicle crashes (Weiss, 1994;
Solomon et al., 1993; Fouts and Rachow, 1994; Ray et al., 1993; Winger, 1993). By contrast, some
shorter acting benzodiazepines are not as likely to produce toxic or
dependence-inducing effects with chronic dosing. One reason is that these
drugs have no active metabolites. Furthermore, because the oxidative pathway
is often impaired in older adults and in those with liver disease, it is
best to choose drugs that are not metabolized by this pathway. Such drugs
include oxazepam (Serax) and lorazepam. Because of these unpleasant and
potentially hazardous side effects of many benzodiazepines, the Panel
recommends caution in selecting the most appropriate benzodiazepine for
elderly patients.

Unfortunately, both long- and short-acting benzodiazepines tend to result in
physiological dependence, even when these medications are taken at
therapeutic doses and for as short a period as 2 months (Woods and Winger, 1995). Many of the
most unpleasant withdrawal effects can be alleviated by gradually tapering
the dose rather than stopping it abruptly. Even if the dose is tapered,
however, withdrawal symptoms are experienced by 40 to 80 percent of people
who discontinue benzodiazepines after 4 to 6 months of regular use (Miller et al., 1985; Speirs et al., 1986). Such symptoms
as anxiety, agitation, lethargy, nausea, loss of appetite, insomnia,
dizziness, tremor, poor coordination, difficulty concentrating,
depersonalization, or confusion may occur after stopping either long or
short half-life benzodiazepines. Symptoms usually peak toward the end of the
tapered discontinuation and disappear altogether within 3 to 5 weeks (Winger, 1993;
Rickels and Schweizer, 1993). In a
few psychiatric patients, the withdrawal syndrome has been known to persist
for several months (Solomon et al.,
1993).

The rebound effects experienced in withdrawal usually mimic the original
symptoms for which the benzodiazepine was prescribed (e.g., anxiety,
insomnia, panic). Those effects occur in as many as one-third to one half of
patients after even 1 or 2 months of benzodiazepine therapy, may be more
intense than before treatment began, and are frequently misperceived by
frightened patients as a return of the initial problem
(Rickels and Schweizer, 1993;
Salzman, 1993b). Rebound
effects, however, are sudden and transient, whereas a relapse entails a
gradual but persistent return of the original symptoms that may continue
unabated unless treated again with benzodiazepines or other appropriate
medications (Rickels and Schweizer,
1993).

Unfortunately, misperceived rebound effects may lead some patients to
self-medicate by supplementing doses during withdrawal unless the tapering
is sufficiently gradual to ameliorate symptoms and the patient is counseled
that these rebound effects are transient and to be expected
(Rickels and Schweizer, 1993).
Unlike withdrawing from alcohol, however, the difficulty in abstaining
during the acute phase of benzodiazepine withdrawal is not followed by any
further craving once the patient is drug-free (Winger, 1993). It appears that most patients
withdrawn from benzodiazepines can maintain abstinence.

The question of whether the benefits outweigh the disadvantages of chronic
benzodiazepine therapy is far from settled. Followup studies have found that
more than half of patients (50 to 66 percent) treated with benzodiazepine
anxiolytics or hypnotics experience a relapse of the original symptoms
within a year of discontinuing benzodiazepine use (Atkinson et al., 1992). Half of these patients
resume use of benzodiazepines. Longer followup studies indicate that a
majority eventually resume use, whether intermittently or chronically (Finlayson, 1984). The reasons for
discontinuation have to be examined in an individually calculated
risk-benefit model by weighing the linkage between untreated anxiety or
insomnia and alcoholism, depression, and suicide (Woods and Winger, 1995). Many researchers, moreover,
argue that anxiety is undermedicated with benzodiazepines and that as many
as 60 percent of patients who have legitimate medical or psychological
reasons for high levels of stress and anxiety do not seek or obtain relief
for these conditions (Salzman,
1993a).

Salzman (1993b) makes a compelling
case that chronic benzodiazepine use may be appropriate for patients he
characterizes as older (but not necessarily elderly), with a number of
chronic illnesses and compromised physical and/or psychosocial functioning.
This group includes patients who are often in pain, dysphoric, or depressed
as well as anxious, suffering from insomnia, or willing to visit their
physicians. Chronic users of this type may experience side effects from
benzodiazepines or incur mild interactions with other drugs they are taking,
but they are not purposefully abusing psychoactive drugs or mixing them with
alcohol. Benzodiazepine prescriptions seem to be clearly indicated for
patients with overwhelming stress or anxiety that compromises functioning
for short periods of time and for chronically medically ill, usually older,
patients (Salzman, 1993b).

One new drug, the serotonin agonist buspirone, is a promising alternative to
benzodiazepines for the treatment of chronic anxiety with associated
depressive symptoms. It apparently produces minimal sedative effects and
little or no impairment of cognitive or psychomotor functioning, is not
synergistic with most other psychoactive drugs or alcohol, and has little
observed potential for causing tolerance or dependence, withdrawal, or
overdose. Buspirone does not have the muscle relaxant or anticonvulsant
properties of benzodiazepines. However, it does have some side effects at
higher doses, and it is not immediately or invariably effective in
ameliorating anxiety. The efficacy of buspirone for older patients is still
being examined; it may precipitate some manic effects. Also, dosages should
be reduced for those with decreased renal or hepatic functioning (Winger, 1993;
Weiss, 1994; Ray et al., 1993; Bezchlibnyk-Butler and Jeffries, 1995).

Sedative/Hypnotics

Sleep disturbances are a common complaint among older adults, occurring in
approximately half of Americans over age 65 who live at home and in
two-thirds of those in long-term care facilities. Complaints about insomnia,
which increase with advancing age, occur in conjunction with a variety of
psychiatric, medical, or pharmacological problems as well as the changing
circadian rhythms that accompany the aging process (National Institutes of Health, 1990; Fouts and Rachow, 1994;
Mullan et al., 1994).

As previously noted, benzodiazepines have replaced older and more toxic
hypnotics (e.g., secobarbital, ethchlorvynol, glutethimide), which have a
high addiction liability and difficult-to-treat overdose potential and which
also tend to accumulate in older adults with chronic dosing as their
capabilities for drug absorption and elimination diminish (Solomon et al., 1993; Bezchlibnyk-Butler and Jeffries,
1995). Nearly two out of five prescriptions for benzodiazepines (38
percent) in 1991 were written for older patients (National Institutes of Health, 1990; Fouts and Rachow, 1994). As with
anxiolytics, the shorter acting hypnotic benzodiazepines are generally
favored over longer acting ones that tend to accumulate in older adults and
produce undesirable effects in the central nervous system. Today, the most
commonly prescribed hypnotic benzodiazepines are oxazepam, temazepam,
triazolam, and lorazepam (Fouts and
Rachow, 1994).

Unfortunately, hypnotic benzodiazepines, like the anxiolytics, also tend to
be prescribed for longer than needed for efficacy, a situation that leads to
the well-known drawbacks of withdrawal and rebound insomnia (Fouts and Rachow, 1994). In 1990,
for example, 23 percent of adults who used benzodiazepine hypnotics (mostly
the short-acting triazolam) had used them nightly for at least 4 months
(Woods and Winger, 1995).

Figure 3-4 displays information
about some sedative/hypnotics frequently prescribed for insomnia, listing
the generic name, the common trade name, and the elimination half-life or
expected duration of action in the body. The commonly prescribed oxazepam
and lorazepam are listed with the benzodiazepine anxiolytics.

Although aging changes sleep architecture, decreasing the amount of time
spent in the deeper levels of sleep (stages three and four) and increasing
the number and duration of awakenings during the night, these new sleep
patterns do not appear to bother most medically healthy older adults who
recognize and accept that their sleep will not be as sound or as regular as
when they were younger (National
Institutes of Health, 1990; Mullan et
al., 1994). Rather, insomnia complaints among older adults
are usually associated with a secondary medical or psychiatric disorder,
psychosocial changes and stressors, or the use of medications that interfere
with sleep (National Institutes of
Health, 1990; Mullan et al.,
1994).

aRefer to product information insert for each drug as to its suitability for
use in older adults.

Among the drugs causing poor sleep patterns are the antidepressant monoamine
oxidase (MAO) inhibitors and SSRIs; anti-Parkinson medications; appetite
suppressors; the beta-blocker for hypertension, propranolol (Inderal); and
alcohol. Sleep apnea, in particular, may be aggravated by the use of a
benzodiazepine (Culebras, 1992).
Insomnia has also been related to depression and anxiety, Alzheimer's
disease, Parkinson's disease, cardiovascular disease, arthritis, pain,
urinary problems, prostate disease, pulmonary disease, hyperthyroidism, and
endocrinopathies. Sleep disruption as well as anxiety commonly accompany
other psychosocial adjustments such as retirement, bereavement, dislocation,
or traumatic situations (National
Institutes of Health, 1990; Mullan et
al., 1994). Sleep complaints are also associated with
female gender, living alone or in a nursing facility, activity limitations,
and sleep habits such as excessive daytime napping
(Mullan et al., 1994).

With respect to treatment of insomnia, a 1990 National Institutes of Health
consensus development conference statement pertaining to sleep disorders of
older adults specifically cautioned against relying on hypnotic
benzodiazepines as the mainstay for managing insomnia
(National Institutes of Health,
1990). Although these medications can be useful for short-term
amelioration of temporary sleep problems, no studies demonstrate their
long-term effectiveness beyond 30 continuous nights, and tolerance and
dependence develop rapidly (Mullan et al.,
1994; National
Institutes of Health, 1990; Salzman, 1993b). In fact, symptomatic treatment of insomnia with
medications should be limited to 7 to 10 days with frequent monitoring and
reevaluation if the prescribed drug will be used for more than 2 to 3 weeks.
Intermittent dosing at the smallest possible dose is preferred, and no more
than a 30-day supply of hypnotics should be prescribed. Given the changes
associated with drug metabolism among older patients, all hypnotic
medications should be used with caution, especially those with long
half-lives (National Institutes of
Health, 1990; Fouts and
Rachow, 1994; Mullan et al.,
1994). As with the anxiolytic benzodiazepines, withdrawal
effects signifying physiological dependence are common concomitants of
precipitous medication discontinuation, especially of the short-acting
compounds. The REM sleep rebound effects from abruptly stopping a
chronically administered benzodiazepine hypnotic can last 1 to 3 weeks or
longer (Mullan et al., 1994; Fouts and Rachow, 1994).

Furthermore, sedative/hypnotics, as well as benzodiazepines, used for sleep
induction may cause confusion and equilibrium problems in older users who
get up frequently during the night (e.g., to go to the bathroom). When
treating older adults, situations likely to increase the incidence of falls
with subsequent injury should be avoided at all costs. In addition, drugs
taken at night for sleep induction will be potentiated by any alcohol the
individual has used during the evening.

Instead of relying on drugs as a first line of approach, treatment should
initially be directed toward any underlying disorder (e.g., depression,
alcoholism, panic states, anxiety) (Mullan et al.,
1994). Having the patient keep a sleep diary may be useful
for obtaining a more objective clarification of sleep patterns because
insomnia is notoriously subjective. Also, the importance of good sleep
hygiene cannot be underestimated (Mullan et al.,
1994; National
Institutes of Health, 1990; Fouts and Rachow, 1994). Patients may need to be educated about
regularizing bedtime, restricting daytime naps, using the bedroom only for
sleep and sexual activity, avoiding alcohol and caffeine, reducing evening
fluid intake and heavy meals, taking some medications in the morning,
limiting exercise immediately before retiring, and substituting behavioral
relaxation techniques (National
Institutes of Health, 1990; Fouts and Rachow, 1994).

Withdrawal from sedative/hypnotic medications (as well as anxiolytics) should
be carefully monitored. Withdrawal is characterized by increased pulse rate,
hand tremor, insomnia, nausea or vomiting, and anxiety. A grand mal seizure
may occur in as many as 20 to 30 percent of dependent persons if withdrawal
symptoms are untreated. Hallucinations similar to those associated with
alcoholic delirium tremens (DTs) may also be present.

Several precautions about particular drugs should be noted. Specifically,
triazolam rapidly achieved notoriety and was banned in the United Kingdom
and other European countries after its 1979 introduction with accompanying
reports of bizarre, idiosyncratic panic and delusional reactions as well as
adverse side effects of confusion, agitation, and anxiety (Woods and Winger, 1995; Winger, 1993). More serious side
effects are still more consistently and more frequently reported with
triazolam than with temazepam, a similar short-acting hypnotic
benzodiazepine (Woods and Winger,
1995). It appears that older patients are more likely than younger
ones to experience increased sedation and psychomotor impairment with this
medication and to report an increased incidence of adverse behavioral
reactions if the dose is greater than 0.125 mg (Fouts and Rachow, 1994).

Another recently introduced but popular hypnotic, zolpidem (Ambien), does not
have the anxiolytic, muscle relaxant, or anticonvulsant properties of
benzodiazepines. It has been touted as a safer sleep medication because it
does not disrupt physiological sleep patterns at low doses and appears to
have relatively mild, dose-related adverse effects. However, zolpidem is
much more costly than the benzodiazepines, an important consideration for
low-income older patients. Also, lower doses (beginning at 5 mg) must be
used in older patients to avoid hazardous confusion and falls (Winger, 1993; Fouts and Rachow, 1994; Ray et al., 1993; Bezchlibnyk-Butler and Jeffries, 1995). Because of its recent
introduction, there is limited information available on the possible
undesirable effects of zolpidem for the older patient.

Several antihistamines, usually used for relief of allergies and available as
over-the-counter medications, are also taken as sleeping aids because of
their sedating properties (e.g., Benadryl). Antihistamines are also combined
with over-the-counter analgesics and marketed as nighttime pain medications
(e.g., Tylenol PM). However, older adults appear to be more susceptible to
adverse anticholinergic effects from these substances and are at increased
risk for orthostatic hypotension and central nervous system depression or
confusion. In addition, antihistamines and alcohol potentiate one another,
further exacerbating the above conditions as well as any problems with
balance. Because tolerance develops within days or weeks, these
antihistamines have questionable efficacy and are not recommended for older
adults who are living alone (Ray et al.,
1993; Fouts and Rachow,
1994; National Institutes of
Health, 1990; Bezchlibnyk-Butler and Jeffries, 1995).

Opiate/Opioid Analgesics

An estimated 2 to 3 percent of noninstitutionalized older adults receive
prescriptions for opioid analgesics (Ray
et al., 1993). Opioids are undeniably effective for management of
severe pain such as that occurring after surgery and serious trauma and
periodically in some medical illnesses (e.g., gout, inflammatory bowel
disease). This acute pain is usually short-lived and resolves within days to
weeks at most. Opioid analgesics are also used to treat cancer-related pain,
which is experienced by nearly all patients with advanced disease and by
one-third-to-one-half of patients in earlier stages. The use of opioid
medications for these purposes is widely acceptable in medical practice
(Portenoy, 1993).

In addition to the rapid development of tolerance and physiological
dependence, other problems are associated with opioid prescriptions for
older patients. Opioid dose requirements decrease with age: The onset of
action is slowed by the decreased rate of gastrointestinal absorption of
orally ingested narcotics, and the duration of action is longer because of
older patients' decreased metabolism and liver functioning. Older adults
also have more adverse side effects because of changes in receptor
sensitivity with age. The less potent opioids, codeine and propoxyphene
(Darvon), cause sedation and mild, dose-related impairment of psychomotor
performance, whereas the more potent opioids, oxycodone (Percodan) and
intramuscular meperidine (Demerol), induce substantial impairment of vision,
attention, and motor coordination. No apparent relation between age and
sedation is observed in patients treated with morphine and pentazocine
(Talwin) (Solomon et al., 1993;
Ray et al., 1993).

The prescribing of opioid analgesics for chronic nonmalignant pain (not
associated with cancer) is a controversial issue. Although long-term
treatment of chronic pain with opiates or opioids has not traditionally been
accepted by either patients or physicians, a growing body of evidence
suggests that prolonged opioid therapy may be both effective and feasible.
Convincing and persuasive testimony has also been given by a number of
clinicians and medical associations regarding the successful management of
lengthy opioid treatment in patients with chronic nonmalignant pain (Portenoy, 1993).

These advocates note that both acute and chronic pain in the United States is
more usually under- than overmedicated for a variety of patient- and
provider-related reasons, not the least of which is fear of addiction. In
addition, patients may believe that stoicism is virtuous, that pain is an
inevitable and intractable part of the illness or disease, or that
prescribed medications are too costly, too complex to manage, or likely to
have numerous and undesirable side effects. Clinicians also may
underprescribe because of fear of sanctions (Portenoy, 1993).

The disagreements among clinicians regarding management of long-term opioid
therapy reflect different perspectives regarding the dangers and persistence
of psychological dependence following physical addiction and the potential
for psychosocial disintegration into an addictive, drug-abusing lifestyle.
Many researchers point out that clinical populations can be successfully
withdrawn from opiates and opioids without dire consequences. One study, for
example, found that only 4 of nearly 12,000 patients who were prescribed
morphine for self-administration became addicted (Chapman and Hill, 1989). Other practitioners argue
that patients' quality of life improves (e.g., less medical care
utilization) if they are kept on opioids and manage pain without addiction
(Finlayson et al., 1986a,
1986b). Also, opioid analgesics
are usually contraindicated if the patient has a history of alcoholism or
another substance abuse or dependence disorder.

Opioid withdrawal is accompanied by restlessness, dysphoric mood, nausea or
vomiting, muscle aches, tearing and yawning, diarrhea, fever, and insomnia.
Although opioid withdrawal is uncomfortable, it is not life-threatening or
particularly dangerous compared with untreated withdrawal from
benzodiazepines.

Figure 3-5 displays information
about some of the more commonly prescribed opiate/opioid analgesics, listing
the generic and brand names with comments about indications and effects.

Interactions With Other Drugs and With
Alcohol

Drug-drug and drug-alcohol interactions are of increased importance in older
adults for several reasons. Because older adults take more prescription and
over-the-counter drugs than younger adults and many continue to drink, the
potential for interactions is enhanced. An interaction is likely to be more
problematic in an older adult because of slowed metabolic and clearance
mechanisms, resulting in a delay in the resolution of the unfavorable reaction.
The aging body is also more susceptible to adverse interactions. The presence of
chronic diseases tends to increase the number of medications used by older
adults. Thus the risk for drug interactions is increased in those for whom an
adverse reaction would be most dangerous. Further research is needed on specific
drug-drug interactions and on drug-alcohol combinations that can be deadly, such
as alcohol and diazepam.

Source:
Korrapati and Vestal, 1995.

Any use of drugs and alcohol carries risk, abuse of these substances raises the
risk, and multiple drug abuse (polypharmacy) further increases the risk. A
recent study documented the many possible unfavorable reactions between
prescription drugs and alcohol (Korrapati and Vestal,
1995) (see Figure
3-6). For example, chronic alcoholics who use even therapeutic doses of
acetaminophen may experience severe hepatoxicity. Alcohol can increase lithium
toxicity and enhance central nervous system depression in persons taking
tricyclic antidepressants. High doses of benzodiazepines used in conjunction
with alcohol or barbiturates can be lethal (American Psychiatric Association, 1994).

Drug-drug interactions can be extremely dangerous and dramatic - the combination
of meperidine with an MAO inhibitor can cause marked blood pressure
fluctuations, excitability, rigidity, hyperreflexia, hyperthermia, coma, and
even death. More often, however, such interactions produce subtle or mild
quantitative effects. A change in sleep, appetite, or an increase in anxiety may
be the only sign and could lead a clinician to increase the dose of a medication
that is already contributing to the adverse reaction. To use psychoactive
prescription and over-the-counter drugs wisely, both physicians and consumers
need to understand how the aging process influences responses to medication and
to recognize how vulnerable older adults are both to their misuse and abuse.